Sunday, April 11, 2010

Haiti: Day 7

On Patients

Most of the patients we’ve had have been pretty straightforward. The vast majority, even the ones we don’t see, have a poor appetite, poor sleep and frequent GI complaints. But a few have been somewhat more complicated.

Two days ago, I saw a 21 year old woman who most likely is a first break schizophrenic . As one might imagine, given the subtleties in translation and cultural nuance, on top of the usual difficulties in obtaining an accurate history from a patient, we must be very careful in giving such diagnoses. For one, the patients here tend to describe their symptoms very figuratively. One gentleman came to me saying he was hearing sounds, when actually he had ringing in his ears after a head trauma. The same patient told me he had a brick on top of his head (headache.) Others have described seeing visions, but careful dissection reveals that those visions are actually memories. This woman, however, reported hearing voices she didn’t recognize for several years prior to the earthquake, though they have worsened since. She exhibited classic symptoms of schizophrenia, including inappropriate affect, thought disorganization and bizarre behavior. Strengthening my faith in the diagnosis were the nursing student’s subjective observations, since as a foreigner I can’t confidently say what is or is not out of the cultural norm. This is why it is so critical to teach the students psychiatric diagnostic skills…because once they are taught, they can do a better job at it than any foreigner. Our patient received a week’s worth of risperidone 1mg po qhs and a follow-up visit with me next week.

Yesterday, we admitted our first patient to the hospital. She was a forty-one year old woman who was referred to us because reportedly she had not eaten or had anything to drink since the earthquake. At the time, they had found no medical reason why she wasn’t eating. James talked to her and her family, and found that she had a history of psychosis prior to the earthquake. She was extremely emaciated, and definitely malnourished. Upon the interview, James decided the patient needed to be hospitalized…I ran over to the hospital, grabbed a stretcher, and with the help of one of the clinic translators, transported her over to the hospital. The docs set her up with an IV, and soon she was feeling a little better. That afternoon, they wanted to send her home, but on our suggestion, agreed to keep her for a while. Today, just as we were headed over to the hospital with the students to round on our patient, Christina (a fourth year med student who does a great job managing the ER) told me they were sending her for a chest film, as they were suspecting TB. Sure enough, the film appeared to reveal TB and she was sent to the sanitarium. Maybe saved her life.

Also yesterday, we saw our first official child and adolescent cases. The adolescent was a bright, energetic thirteen year-old girl who came to the clinic for her nasal congestion. She was a typical thirteen year-old girl, who I imagine were she in the states, would spend most of her time talking a mile a minute on her cell phone. Ali had a hard time keeping up with her! Though she had lost several family members in the earthquake, she actually was doing pretty well, and just came to see us because she was upset by the aftershock I described yesterday.

Our child case was a little more complicated. He was a ten year old boy referred to us because his sister stated that since the earthquake, he hasn’t spoken. So…sheltered space being at a premium, our office became our Kid’s Corner. I found some toys at the residence, and started playing with him while James, Ali and the students interviewed the sister. She said he had been a normal little boy, got good grades in school, played with his friends, but all that changed after the earthquake. He had a leg injury, but she couldn’t give a clear history about when it happened. It seems he wasn’t injured at all in the earthquake. From his play, I immediately had serious doubts about the veracity of the given history. I gave him a notepad to write/draw on, and he happily began to draw repetitive circles all over the page. He drooled continuously, and flashed me a huge smile after he finished each line of circles. He couldn’t talk, but would give me a merry grunt when I’d say “Hi”. I asked him to draw a picture of his sister…he drew circles. I asked him to write his name…he drew circles. The sister soon admitted that he never could write his name. Suspecting MR, Ali explained to me there was a huge stigma in the country about MR/DD children. Parents will often say that some event caused the child to have his or her difficulties. They hope that the doctors can give them a medication that will make everything better. I wish that I could.

1 comment:

  1. Kobie, I daresay that your recognition of what was happening with the child you describe is well beyond of what I would have ever recognized. My hat is off to you. Thank you for sharing this.